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Corps action ID no.
DWQ project no.
Form Version 1.4 January 2009
Pre-Construction Notification (PCN) Form
A. Applicant Information
1. Processing
1 a. Type(s) of approval sought from the Corps: ❑ Section 404 Permit Section 10 ❑ rmit
1b. Specify Nationwide Permit (NWP) number: 3 or General Permit (GP) number:
1 c. Has the NWP or GP number been verified by the Corps? ❑ Yes ❑X No
1 d. Type(s) of approval sought from the DWQ (check all that apply):
❑ 401 Water Quality Certification — Regular ❑ Non-404 Jurisdictional General Permit
❑ 401 Water Quality Certification — Express ❑ Riparian Buffer Authorization
1 e. Is this notification solely for the record For the record only for DWQ For the record only for Corps Permit:
because written approval is not required? 401 Certification:
❑X Yes ❑ No ❑ Yes ❑X No
1f. Is payment into a mitigation bank or in-lieu fee program proposed for
mitigation of impacts? If so, attach the acceptance letter from mitigation bank � Yes ❑X No
or in-lieu fee program.
1 g. Is the project located in any of NC's twenty coastal counties. If yes, answer 1 h � Yes ❑X No
below.
1 h. Is the project located within a NC DCM Area of Environmental Concern (AEC)? ❑ Yes ❑X No
2. Project Information
2a. Name of project: Bridge #25
2b. County: Moore
2c. Nearest municipality / town: Jackson Springs
2d. Subdivision name:
2e. NCDOT only, T.I.P. or state project no: Project #17BP.8.R.116
3. Owner Information
3a. Name(s) on Recorded Deed: NCDOT Highway Division 8
3b. Deed Book and Page No.
3c. Responsible Party (for LLC if
applicable):
3d. Street address: 902 North SandhillsBlvd
3e. City, state, zip: Aberdeen, NC 28315
3f. Telephone no.: 910-944-2344
3g. Fax no.: 910-944-5623
3h. Email address: [e-mail]
Page 1 of 10
PCN Form — Version 1.4 January 2009

4. Applicant Information (if different from owner)
4a. Applicant is: ❑X Agent ❑ Other, specify:
4b. Name:
4c. Business name
(if applicable):
4d. Street address:
4e. City, state, zip:
4f. Telephone no.:
4g. Fax no.:
4h. Email address:
5. Agent/Consultant Information (if applicable)
5a. Name: Art C. King
5b. Business name NCDOT
(if applicable):
5c. Street address: 902 North Sandhills Blvd.
5d. City, state, zip: Aberdeen, NC 28315
5e. Telephone no.: 910-944-2344
5f. Fax no.: 910-944-5623
5g. Email address: [e-mail]
Page 2 of 10

B. Project Information and Prior Project History
1. Property Identification
1a. Property identification no. (tax PIN or parcel ID): Not applicable
1 b. Site coordinates (in decimal degrees): Latitude: 35.191381 Longitude: 79.361803
1 c. Property size: 0.9 acres
2. Surface Waters
2a. Name of nearest body of water to proposed project: Jackson Creek
2b. Water Quality Classification of nearest receiving water: WS-II, HQW
2c. River basin: Lumber
3. Project Description
3a. Describe the existing conditions on the site and the general land use in the vicinity of the project at the time of this
application:
Rural residential, Forested
3b. List the total estimated acreage of all existing wetlands on the property: 0.1
3c. List the total estimated linear feet of all existing streams (intermittent and perennial) on the property: 120
3d. Explain the purpose of the proposed project:
To replace an obsolete bridge with a modern safer structure.
3e. Describe the overall project in detail, including the type of equipment to be used:
To demolish the existing bride from the top down and replace it with a structure that will span the existing channel. equipment :Dump trucks, cranes,Tra
4. Jurisdictional Determinations
4a. Have jurisdictional wetland or stream determinations by the 0 Yes ❑ No ❑ Unknown
Corps or State been requested or obtained for this property /
ro'ect includin all rior hases in the ast? Comments:
4b. If the Corps made the jurisdictional determination, what type � Preliminary ❑ Final
of determination was made?
4c. If yes, who delineated the jurisdictional areas? Agency/Consultant Company: ECOLOGICAL ENGINEERING, �
Name (if known): �avid G. Cooper Other:
4d. If yes, list the dates of the Corps jurisdictional determinations or State determinations and attach documentation.
3/23/2016 Data forms included in package.
5. Project History
5a. Have permits or certifications been requested or obtained for �Yes ❑X No ❑ Unknown
this project (including all prior phases) in the past?
5b. If yes, explain in detail according to "help file" instructions.
6. Future Project Plans
6a. Is this a phased project? ❑ Yes ❑X No
6b. If yes, explain.
Page 3 of 10
PCN Form — Version 1.4 January 2009

C. Proposed Impacts Inventory
1. Impacts Summary
1 a. Which sections were completed below for your project (check all that apply):
❑X Wetlands Strea X� — tributaries Buffers Open �ters PQd Construction ❑
2. Wetland Impacts
If there are wetland impacts proposed on the site, then complete this question for each wetland area impacted.
2a. 2b. 2c. 2d. 2e. 2f.
Wetland impact Type of impact Type of wetland Forested Type of jurisdiction Area of
number Corps (404,10) or impact
Permanent (P) or DWQ (401, other) (acres)
Tem ora T
W1 P Fill Bottomland Hardwood Forest Yes/No Corps 0.02
W2 - Choose one Choose one Yes/No -
W$ - Choose one Choose one Yes/No -
W4 - Choose one Choose one Yes/No -
W5 - Choose one Choose one Yes/No -
Wg - Choose one Choose one Yes/No -
2g. Total Wetland Impacts: 0.02
2h. Comments:
Fill from slope construction.
3. Stream Impacts
If there are perennial or intermittent stream impacts (including temporary impacts) proposed on the site, then complete this
question for all stream sites impacted.
3a. 3b. 3c. 3d. 3e. 3f. 3g.
Stream impact Type of impact Stream name Perennial (PER) or Type of Average Impact
number intermittent (INT)? jurisdiction stream length
Permanent (P) or width (linear
Temporary (T) (feet) feet)
S1 P Stabilization Jackson Creek PER Corps 19 60
$2 T Dewatering Jackson Creek PER Corps 19 32
S3 - Choose one - -
S4 - Choose one - -
S5 - Choose one - -
S6 - Choose one - -
3h. Total stream and tributary impacts 92
3i. Camments:
60 ft of Rip rap armoring for permanent bank stabilization to protect the bridge structure.
32 ft of Temporary Impacts for de-watering if needed to install bank stabilization, or to help remove the existing interior bent.
Page 4 of 10
PCN Form — Version 1.4 January 2009

4. Open Water Impacts
If there are proposed impacts to lakes, ponds, estuaries, tributaries, sounds, the Atlantic Ocean, or any other open water of
the U.S. then individuall list all o en water im acts below.
4a. 4b. 4c. 4d. 4e.
Open water Name of waterbody
impact number (if applicable) Type of impact Waterbody Area of impact (acres)
Permanent (P) or type
Tem ora T
01 - Choose one Choose
O2 - Choose one Choose
03 - Choose one Choose
04 - Choose one Choose
4f. Total open water impacts
4g. Comments:
5. Pond or Lake Construction
If ond or lake construction ro osed, then com lete the chart below.
5a. 5b. 5c. 5d. 5e.
Pond ID number Proposed use or Wetland Impacts (acres) Stream Impacts (feet) Upland
purpose of pond (acres)
Flooded Filled Excavated Flooded Filled Excavated
P1 Choose one
P2 Choose one
5f. Total:
5g. Comments:
5h. Is a dam high hazard permit required? ❑ Yes ❑ No If yes, permit ID no:
5i. Expected pond surface area (acres):
5j. Size of pond watershed (acres):
5k. Method of construction:
6. Buffer Impacts (for DWQ)
If project will impact a protected riparian buffer, then complete the chart below. If yes, then individually list all buffer impacts
below. If an im acts re uire miti ation, then ou MUST fill out Section D of this form.
6a. Project is in which protected basin? ❑ Neuse � Tar-Pamlico �tawba �ndleman Oth�
6b. 6c. 6d. 6e. 6f. 6g.
Buffer Impact Reason for impact Stream name Buffer Zone 1 Zone 2
number — mitigation impact impact
Permanent (P) or required? (square (square
Tem ora T feet feet
B� - Yes/No
g2 - Yes/No
g3 - Yes/No
B4 - Yes/No
B5 - Yes/No
gg - Yes/No
6h. Total Buffer Impacts:
6i. Comments:
Page 5 of 10

D. Impact Justification and Mitigation
1. Avoidance and Minimization
1a. Specifically describe measures taken to avoid or minimize the proposed impacts in designing project.
This project is along existing alignment. The proposed roadway grade is very close to that of the existing with only slight improvement to the grade for
safety and speed. Guardrail is kept to a minimum for safety and file slopes are as steep as possible to minimize the bridge length. Rip rap is only
added to stabilize the stream against erosion and protect the structure from failure.
1 b. Specifically describe measures taken to avoid or minimize the proposed impacts through construction techniques.
The bridge type is a single span 55' cored slab bridge which can be set in place without causeways, work pads, or work bridges. A crane will be
utilized to this construction activity. Also there will be an offsite detour to further minimize impacts.
2. Compensato Miti ation for Impacts to Waters of the U.S. or Waters of the State
2a. Does the project require Compensatory Mitigation for � Yes ❑X No
impacts to Waters of the U.S. or Waters of the State?
2b. If yes, mitigation is required by (check all that apply): ❑ DWQ ❑ Corps
❑ Mitigation bank
2c. If yes, which mitigation option will be used for this
project? ❑ Payment to in-lieu fee program
❑ Permittee Responsible Mitigation
3. Complete if Usin a Miti ation Bank
3a. Name of Mitigation Bank:
Type: Choose one Quantity:
3b. Credits Purchased (attach receipt and letter) Type: Choose one Quantity:
Type: Choose one Quantity:
3c. Comments:
4. Com lete if Makin a Pa ment to In-lieu Fee Pro ram
4a. Approval letter from in-lieu fee program is attached. ❑ Yes
4b. Stream mitigation requested: linear feet
4c. If using stream mitigation, stream temperature: Choose one
4d. Buffer mitigation requested (DWQ only): square feet
4e. Riparian wetland mitigation requested: acres
4f. Non-riparian wetland mitigation requested: acres
4g. Coastal (tidal) wetland mitigation requested: acres
4h. Comments:
5. Complete if Using a Permittee Responsible Mitigation Plan
5a. If using a permittee responsible mitigation plan, provide a description of the proposed mitigation plan.
Page 6 of 10
PCN Form — Version 1.4 January 2009

6. Buffer Mitigation (State Regulated Riparian Buffer Rules) — required by DWQ
6a. Will the project result in an impact within a protected riparian buffer that requires � Yes ❑X No
buffer mitigation?
6b. If yes, then identify the square feet of impact to each zone of the riparian buffer that requires mitigation. Calculate the
amount of mitigation required.
6c. 6d. 6e.
Zone Reason for impact Total impact Multiplier Required mitigation
(square feet) (square feet)
Zone 1 3(2 for Catawba)
Zone 2 1.5
6f. Total buffer mitigation required:
6g. If buffer mitigation is required, discuss what type of mitigation is proposed (e.g., payment to private mitigation bank,
permittee responsible riparian buffer restoration, payment into an approved in-lieu fee fund).
6h. Comments:
Page 7 of 10

E. Stormwater Management and Diffuse Flow Plan (required by DWQ)
1. Diffuse Flow Plan
1 a. Does the project include or is it adjacent to protected riparian buffers identified � Yes ❑X No
within one of the NC Ri arian Buffer Protection Rules?
1 b. If yes, then is a diffuse flow plan included? If no, explain why.
❑ Yes � No
2. Stormwater Mana ement Plan
2a. What is the overall percent imperviousness of this project? 33 %
2b. Does this ro'ect re uire a Stormwater Mana ement Plan? ❑X Yes ❑ No
2c. If this project DOES NOT require a Stormwater Management Plan, explain why:
HQW stream. Plan included in the package
2d. If this project DOES require a Stormwater Management Plan, then provide a brief, narrative description of the plan:
Plan attached.
2e. Who will be responsible for the review of the Stormwater Management Plan? NCDEQ
3. Certified Local Government Stormwater Review
3a. In which local overnmenYs 'urisdiction is this ro'ect?
❑ Phase II
3b. Which of the following locally-implemented stormwater management programs ❑ NSW
apply (check all that apply): ❑ USMP
� Water Supply Watershed
� Other:
3c. Has the approved Stormwater Management Plan with proof of approval been ❑Yes ❑ No
attached?
4. DWQ Stormwater Pro ram Review
�Coastal counties
❑X HQW
4a. Which of the following state-implemented stormwater management programs apply �ORW
(check all that apply):
❑ Session Law 2006-246
❑ Other:
4b. Has the approved Stormwater Management Plan with proof of approval been ❑X Yes ❑ No
attached?
5. DWQ 401 Unit Stormwater Review
5a. Does the Stormwater Management Plan meet the appropriate requirements? ❑ Yes ❑ No
5b. Have all of the 401 Unit submittal requirements been met? � Yes � No
Page 8 of 10
PCN Form — Version 1.4 January 2009

F. Supplementary Information
1. Environmental Documentation (DWQ Requirement)
1 a. Does the project involve an expenditure of public (federal/state/local) funds or the 0 Yes ❑ No
use of public (federal/state) land?
1 b. If you answered "yes" to the above, does the project require preparation of an
environmental document pursuant to the requirements of the National or State ❑ Yes ❑X No
(North Carolina) Environmental Policy Act (NEPA/SEPA)?
1 c. If you answered "yes" to the above, has the document review been finalized by the
State Clearing House? (If so, attach a copy of the NEPA or SEPA final approval
letter.) ❑ Yes ❑ No
Comments:
2. Violations (DWQ Requirement)
2a. Is the site in violation of DWQ Wetland Rules (15A NCAC 2H .0500), Isolated
Wetland Rules (15A NCAC 2H .1300), DWQ SurFace Water or Wetland Standards, ❑Yes ❑X No
or Riparian Buffer Rules (15A NCAC 2B .0200)?
2b. Is this an after-the-fact permit application? ❑Yes ❑X No
2c. If you answered "yes" to one or both of the above questions, provide an explanation of the violation(s):
3. Cumulative Impacts (DWQ Requirement)
3a. Will this project (based on past and reasonably anticipated future impacts) result in �Yes ❑X No
additional development, which could impact nearby downstream water quality?
3b. If you answered "yes" to the above, submit a qualitative or quantitative cumulative impact analysis in accordance with the
most recent DWQ policy. If you answered "no," provide a short narrative description.
4. Sewage Disposal (DWQ Requirement)
4a. Clearly detail the ultimate treatment methods and disposition (non-discharge or discharge) of wastewater generated from
the proposed project, or available capacity of the subject facility.
Page 9 of 10
PCN Form — Version 1.4 January 2009

5. Endangered Species and Designated Critical Habitat (Corps Requirement)
5a. Will this project occur in or near an area with federally protected species or � Yes ❑ No
habitat?
5b. Have you checked with the USFWS concerning Endangered Species Act � Yes ❑X No
impacts?
5c. If yes, indicate the USFWS Field Office you have contacted. -
5d. What data sources did you use to determine whether your site would impact Endangered Species or Designated Critical
Habitat?
USF&W Endangered Species website: https://www.fws.gov/endangered/
Field suroey by NCDOT staff. (check sheet attached)
6. Essential Fish Habitat (Corps Requirement)
6a. Will this project occur in or near an area designated as essential fish habitat? ❑ Yes ❑X No
6b. What data sources did you use to determine whether your site would impact Essential Fish Habitat?
USF&W Endangered Species website: https://www.fws.gov/endangered/
7. Historic or Prehistoric Cultural Resources (Corps Requirement)
7a. Will this project occur in or near an area that the state, federal or tribal
governments have designated as having historic or cultural preservation � Yes ❑X No
status (e.g., National Historic Trust designation or properties significant in
North Carolina history and archaeology)?
7b. What data sources did you use to determine whether your site would impact historic or archeological resources?
NCDOT PDEA staff screening, NCSHPO screening, (Results Attached)
8. Flood Zone Designation (Corps Requirement)
8a. Will this project occur in a FEMA-designated 100-year floodplain? ❑ Yes ❑X No
8b. If yes, explain how project meets FEMA requirements:
8c. What source(s) did you use to make the floodplain determination?
NCDOT Stormwater Management Report
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letter from the a licant is rovided.
Page 10 of 10